Retinal detachment occurs when the neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium. It is a reversible cause of visual loss, provided it is recognised and treated before the macula is affected. If left untreated and symptomatic, retinal detachment will inevitably lead to permanent visual loss. Children tend to have poorer prognosis, but this may be due to late detection.

Risk factors:

• Age
• Previous surgery for cataracts (accelerates posterior vitreous detachment)
• Myopia
• Eye trauma (consider boxing)
• Family history
• Previous history of retinal break/detachment in either eye

Detachment should be suspected if patients complain of new-onset floaters or flashes, as these indicate pigment cells entering the vitreous space or traction on the retina respectively. Sudden onset, painless and progressive visual field loss, described as a curtain or shadow progressing to the centre of the visual field from the periphery should also raise suspicion of detachment. If the macula is involved, central visual acuity and visual outcomes become much worse.

In infants, retinal detachment may present with a squint or a white pupillary reflex. It should be suspected if there is a history of ocular trauma with older children, as they are unlikely to comment on visual changes.

On examination, peripheral visual fields may be reduced, and central acuity may be reduced to hand movements if the macula is detached. The swinging light test may highlight a relative afferent pupillary defect if the optic nerve is involved. On fundoscopy, the red reflex is lost and retinal folds may appear as pale, opaque or wrinkled forms. If the break is small, however, it may appear normal.

Any patients with new onset flashes and floaters should be referred urgently (<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage.